Updates & Features
Psychological Therapy in Pain
May 2018
Pain is not all in a patient’s head, but can psychotherapy help?
PainSolve Editorial Team
The psychology of pain
Chronic pain is a highly intractable issue that is encountered by clinicians across hundreds of medical conditions.1 Pain can have multiple consequences for affected individuals, including increasing the likelihood for depression, inability to work, disruption to personal relationships, and suicidal thoughts.2 Chronic pain is also frequently accompanied by comorbid psychological disorders, together resulting in significant disability (as measured by impairment of daily activities).2 Since the 1960s, there has been progress in advancing understanding of pain, from seeing pain as a purely physical sensation to recognition that pain can often be a biopsychosocial phenomenon with far-ranging effects on biological, psychological and emotional processes.3,4 This view is reflected in the International Association for the Study of Pain (IASP) definition of pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’.5
Whilst the mechanisms behind the development of chronic pain are incompletely understood, one important contributor that has been identified is perceived stress and stress response systems.1 Supporting patients in better understanding their cognitive and emotional modulation of pain, and promoting self-management techniques through psychological treatments could be an overlooked, but key, part of the puzzle to solving pain.1
Psychological therapies as a tool to manage chronic pain
Psychological interventions are a recommended feature of a modern pain treatment service, where they can be effectively combined with medical treatment as part of the multidisciplinary management of chronic pain.6 Psychological therapies for pain are presumed to confer a low risk for adverse effects to the recipient.7 Rather than focusing on resolution of pain itself, psychotherapy for chronic pain primarily aims to improve physical, emotional, social, and occupational functioning.7
“There is no treatment for patients with chronic pain that makes a bigger difference than our empathy and our time.”1
Psychological therapies for chronic pain fall into four key categories (see table below):7
| Therapeutic modality | Description of treatment | Pain disorders with demonstrated efficacy |
| Operant-behavioural therapy | Treatment focuses on modifying behavioural responses though reinforcement and punishment contingencies, and extinction of associations between the threat value of pain and physical behaviour. | Complex regional pain syndromes, lower back pain, mixed chronic pain, whiplash-associated disorders. |
| Cognitive-behavioural therapy (CBT) | A biopsychosocial intervention focused on developing personal coping strategies. CBT protocols may involve psychoeducation about pain, behaviour, and mood, strategies for relaxation, effective communication, and cognitive restructuring for distorted and maladaptive thoughts about pain. | Cancer, chronic lower back pain, chronic headaches, chronic migraines, chronic orofacial pain, complex regional pain syndromes, fibromyalgia, HIV/AIDS, Irritable bowel syndrome, mixed chronic pain, non-specific heart pain, multiple sclerosis, nonspecific musculoskeletal pain, osteoarthritis, rheumatoid arthritis, spinal cord injury, systemic lupus erythematosus, whiplash-associated disorders. |
| Mindfulness-based therapy | A psychotherapy method that promotes a non-judgmental approach to pain and uncoupling of physical and psychological aspects of pain. Meditations and daily mindfulness practice are utilised to increase awareness of the body, breath and proprioceptive signals, and development of mindful activities. | Arthritis, cancer, chronic lower back pain, chronic headache, chronic migraine, complex regional pain syndromes, fibromyalgia, irritable bowel syndrome, rheumatoid arthritis, chronic neck pain. |
| Acceptance and commitment therapy | Treatment based on increasing psychological flexibility through acceptance of mental events and pain, and ceasing of maladaptive attempts to eliminate and control pain through avoidance and other problematic behaviours. | Musculoskeletal pain (full body, lower back, lower limb, neck, upper limb), whiplash-associated disorders. |
Beginning in the late 1970s and early 1980s, approaches to chronic pain based on CBT have become the dominant psychological approach within pain management.8,9 Among the various forms of psychotherapy applied for chronic pain, the evidence base for effectiveness is strongest for CBT.6 In adults, CBT has been evidenced to support marked improvements in quality of life, disability, psychological distress (principally depression) and, to a lesser extent, pain.6 The impact of CBT on pain is stronger in the paediatric population, where it has been described as ‘one of the most successful treatments for paediatric chronic pain’.6
Future directions to improve access to psychotherapy
Given the magnitude of the problem and the modest benefits from traditional medical, pharmacological, and surgical treatments, there is a growing realisation of the importance of considering psychosocial factors when addressing chronic pain and pain-related disability.4 An ideal pain management regimen will be comprehensive, integrative, and interdisciplinary, so including psychological interventions as part of a multimodal approach can provide a safe and effective means to help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain.10
Treatment accessibility may be a limitation for psychological intervention; for example, the availability of psychotherapists with appropriate expertise and experience in supporting patients with chronic pain management is limited in certain healthcare systems.7,9 Similarly, even when specialist support is available, patients in poverty or those living in remote geographical locations may struggle to access these.7 Technology allowing remote access, such as online video therapy sessions or virtual reality clinics, may help to improve access to these psychological therapies in pain management.7,11,12 Delivery of psychological interventions by healthcare professionals other than psychologists (for example nurses or physical therapists), or within collaborative care models in primary care (where a patient’s healthcare needs are supported in an integrated approach involving coordination with social and mental health teams) are gaining interest as innovative approaches to address access barriers.9
References
- Crofford LJ. Trans Am Clin Climatol Assoc 2015; 126: 167–183
- Goldberg DS, McGee SJ. BMC Public Health 2011; 11: 770
- Lumley MA, et al. J Clin Psychol 2011; 67: 942–968
- Jensen MP & Turk DC. Am Psychol 2014; 69: 105–118
- International Association for the Study of Pain (1994) IASP Taxonomy, Pain terms, Pain. Available at: https://www.iasp-pain.org/Taxonomy#Pain (accessed April 2018)
- Eccleston C, et al. Br J Anaesth 2013; 111: 59–63
- Sturgeon JA, et al. Psychol Res Behav Manag 2014; 7: 115–124
- Barker E & McCracken LM. Br J Pain 2014; 8: 98–106
- Ehde DM, et al. Am Psychol 2014; 69: 153–166
- Roditi D & Robinson ME. Psychol Res Behav Manag 2011; 4: 41–49
- Fisher E, et al. Cochrane Database Syst Rev. 2015; 3: CD011118
- Hoch DB, et al. PLoS ONE 7: e33843